Pediatric RISE: Development of a Poverty-Targeted Cash Support Intervention for Pediatric Cancer

Introduction: Poverty is associated with inferior outcomes across the care continuum in pediatric hematologic malignancies despite highly standardized treatment (Winestone, PBC 2023). Evidence-based supportive care interventions targeting poverty in pediatric oncology as a risk factor for outcome disparities are lacking. Unrestricted direct cash transfer programs, such as the Child Tax Credit, are feasible, reduce income poverty, and improve child health outcomes (Shafer, JAMA NO 2022). We aimed to pilot and refine Pediatric RISE (Resource Intervention to Support Equity), the first direct cash transfer intervention in pediatric oncology, as a novel supportive care health equity intervention.

Methods: We conducted a single-arm, mixed-methods pilot study of RISE among children with newly diagnosed (de novo malignancy in prior 2 months) or advanced (relapsed/progressive disease in prior 2 months) cancer at a single, large academic center. Eligible children were Massachusetts residents, had initiated cancer care with planned receipt of ≥4 months of cancer-directed therapy, and lived in parent-reported low-income households (<200% Federal Poverty Level). Participants were directly assigned to RISE—twice-monthly cash disbursements for 3 months in a standardized dollar amount based on the number of household dependents (< age 18) and extrapolated from the Child Tax Credit. A single session with a certified benefits counselor to review household-specific risk of means-tested government benefit loss/reduction due to receipt of RISE dollars was optional. State-specific exemptions from Massachusetts government agencies were obtained to exclude RISE payments from income evaluations for most means-tested benefit programs. Baseline and 3 month quantitative surveys and 1 month and 3 month qualitative interviews evaluated intervention acceptability and utilization barriers to inform RISE refinement.

Results: Twenty of 21 (95%) eligible families consented to participate (n=10 newly diagnosed, n=10 advanced cancer). A majority (65%, n=13) had a hematologic malignancy. Children were identified as White (45%), Hispanic (50%), publicly insured (90%), and living in single-parent households (60%) with a median household income of $27,250 (IQR $8,280, $42,500). Ninety-five percent (n=19) of parents completed all surveys and interviews; 100% of parents completed at least 1 qualitative interview.

Quantitatively, 100% of families successfully received all intended cash disbursements: 75% (n=15) via direct deposit, 20% (n=4) via pre-paid debit card and 5% (n=1) via Venmo/PayPal. Ninety-five percent (n=18) of families were satisfied or very satisfied with RISE, and 95% (n=18) would recommend to others. Parents reported using funds for rent/mortgage, groceries, utilities, and transportation. Parent-reported household material hardship in any domain (food, housing, utility or transportation insecurity) declined from 90% of families at baseline to 74% at 3 months.

Qualitatively, families described RISE as valuable, with positive financial and mental/emotional impacts including peace of mind and ability to spend more time at their child’s bedside. Families characterized RISE as an acceptable intervention from the clinical setting, with limited barriers to use. Parents identified a need for increased RISE dollar amounts and extended RISE duration for at least 6 months to cover basic needs in the context of treatment-related income losses. Parents expressed worry about meeting their financial obligations after RISE conclusion. No families reported reduction or loss of means-tested government benefits due to RISE.

Conclusion: Our novel supportive care health equity intervention utilizing direct cash support to target income-poverty was feasible and highly acceptable to pediatric oncology families. Risk of loss/reduction in means-tested government benefits was appropriately mitigated by intervention design. Qualitative parent feedback informed intervention refinement including an increase in total RISE cash disbursements and duration. The refined RISE contributes to the small portfolio of pediatric oncology equity interventions available for future evaluation of efficacy in reducing outcome disparities; RISE is currently being evaluated in a multi-site, randomized, phase II signal-finding study.